Form Pep 091201 – Fill Out and Use This PDF

ONE STOP PERMITTING

	CITY OF BIRMINGHAM
	DEPARTMENT OF PLANNING, ENGINEERING & PERMITS
	710 20th Street, North
	ROOM 210, CITY HALL
	BIRMINGHAM, ALABAMA 35203
William A. Bell, Sr.	Andre V. Bittas
Mayor	Director

P.I.D. No.					Fee Amount $
Address Verified by:					Bond Amount $
Modified Address

Please print or type legibly and fill in all that apply

(sections with bold borders must be completely filled out before application will be accepted)

Application is hereby made to accomplish the work as herein described in accordance with Plans and Specifications submitted herewith. It is agreed that all corrections in Plans and/or Specifications necessary for compliance shall be observed and all requirements of the Soil Erosion and Sediment Control Ordinance, the Zoning Ordinance, and all other pertinent Laws and Ordinances of the City of Birmingham regulating construction shall be complied within the pursuit of this work, whether or not specified herein.

Site Address

City/State/Zip

Location

Project Name (If multiple lots involved)

Legal Description

Lot(s)

Block(s)

 If no recorded map, attach metes and bounds.

Property Owner – (Please fill in all that apply)

Person, Firm, Agent or Corporation Making Application*

NAME

NAME

ADDRESS:

COMPANY NAME

CITY/STATE/ZIP

ADDRESS:

PHONE(

)

CELLULAR (

)

CITY/STATE/ZIP

FAX(

)

PAGER (

)

PHONE(

)

CELLULAR (

)

E-MAIL

FAX(

)

PAGER (

)

E-MAIL

*Applicant is required to be authorized by owner to undertake work

Plans Drawn By:

Architect

Landscape Architect

Engineer

Contact Person

NAME

NAME

COMPANY NAME

COMPANY NAME

ADDRESS:

ADDRESS:

CITY/STATE/ZIP

CITY/STATE/ZIP

PHONE(

)

CELLULAR (

)

PHONE(

)

CELLULAR (

)

FAX(

)

PAGER (

)

FAX(

)

PAGER (

)

E-MAIL

E-MAIL

Description Of Work

Proposed Use

Is Architectural or Engineering Supervision Included?

Yes

No

If yes, by whom?

Architect

Engineer

Landscape Architect

NAME:

COMPANY NAME:

ADDRESS:

CITY/STATE/ZIP

PHONE:

(

)

CELLULAR: (

)

FAX: (

)

PAGER: (

)

E-MAIL:

Architectural Or Engineering Inspector

NAME:

COMPANY NAME:

ADDRESS:

CITY/STATE/ZIP

PHONE:

(

)

CELLULAR: (

)

FAX: (

)

PAGER: (

)

E-MAIL:

PEP 091201

Plot Information

Plot Area

sq. ft.

Plot Width

front

acres

rear

Acres to be disturbed

Total acres

Amount Fill

Amount Cut

Total Earthwork Cost $

Soil Erosion and Sedimentation Cost

$

For Staff Use

Certification

Prior to any work beginning, the owner listed below agrees to the following:

Hold the City of Birmingham, its officers, agents and employees, harmless from any and all claims made against the City of Birmingham, which arise out of any action or omission of the owner, contractor or subcontractor, or any of their officers, employees or agents, and any and all claims which result from any condition arising out of, created or maintained by the owner, contractor or subcontractor or any of their officers, employees or agents.

That no work, including clearing and/or earthwork shall be performed without first installing all temporary erosion control measures, as shown on the plans, and until the applicant has requested review by the Planning, Engineering and Permits Department of the completed temporary erosion control measures.

That I have read this application and that all information contained herein is true and correct. That I agree to comply with all City ordinances and State laws regulating this construction.

I hereby certify that I have read this application and that all information contained herein is true. If any portion of this information, either intentionally or unintentionally, is false or is a misrepresentation of the material facts, the permit or process granted will be void. I further certify that if I am not the owner, I have proper authorization from the owner to act as representative on his/her behalf and that I may be required to provide written documentation of such authorization to the City of Birmingham.

Signature of Owner or Authorized Agent		Date
Print Full Name Legibly		Date

Reviewed by

Date

PEP 091201